Ethel Higginbotham

Symptoms/subjective data:

  • No appetite
  • Confusion
  • Withdrawn
  • Productive cough
  • Small open lesions on lower legs
  • "I just want to die"

Medical Diagnoses - Pneumonia - Fluid in the lungs

  • Was receiving oxygen

80 yrs old

  • At risk for falls

Collection/objective data: Thin, Weak, refuses to eat, sleeps most of the time

  • At risk for infection
  • Fatigue
  • Frail elderly syndrome
  • Grieving
  • Less than body requirements - imbalanced nutrition
  • Risk for loneliness, social isolation
  • Disturbed sleep pattern
  • Death anxiety

Planning

  • Patient will drink 1 protein shake per day for the next month
  • Patient will gain 1% of her body weight over 1 week
  • Patient will meet with a grief counselor after 1 month of nutrition help
  • Patient will attempt to eat 75% of her meals for the next 2 months

Intervention

  • Nurse will conduct vital signs - Nurse will check why pt went off oxygen - Nurse will work with nutritionist to create a meal plan
  • Risk for pressure ulcer